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Collaborative Stage Update

Collaborative Stage Update. Louanne Currence, RHIT, CTR. Data Items. 15 items in data set 5 existing data items Size, extension, regional nodes 10 new data items Mets at diagnosis 3 “method of evaluation” for T, N, M 6 “site specific” factors Only used if required for TNM.

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Collaborative Stage Update

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  1. Collaborative Stage Update Louanne Currence, RHIT, CTR

  2. Data Items • 15 items in data set • 5 existing data items • Size, extension, regional nodes • 10 new data items • Mets at diagnosis • 3 “method of evaluation” for T, N, M • 6 “site specific” factors • Only used if required for TNM

  3. CS Histology Exclusion Tables • Determines when TNM is applicable to site • Based on statements in AJCC manual • EX: Histology for Lower Lip excludes • 8240/1 carcinoid tumor, uncertain • 8240/3 carcinoid tumor • 8241 Enterochromaffin cell carcinoid • etc carcinoids • T-NA, N-NA, M-NA, Stage NA

  4. Reporting Requirements • COC-approved progams • all 15 CS elements • derived collab stage goes to NCDB • SEER • all CS except eval fields • NPCR • ONLY extension, CS Lymph nodes, Mets at dx, SSF3 (prostate), SSF1 (pleural effus)

  5. Table 1 – Allowable values/format for CS stage (NAACCR #) pg 5-6 Table 2 – SSF Schemas Used pg 13 Table 3 – Histology Specific Coding Schemas pg 15 Table 6 – Schemas NA for AJCC pg 18 Use of Autopsy Info pg 18 Ambiguous Terms pg 20 (like SSM) How To Code CS pg 21 Data Item Instructions pg 25 - 58 Front of the Book

  6. App 1 Determining Descriptive Tumor Size (conversion) App 2a – 2e Allowable Values App 3 Summary Stage Conversion Algorithm for All Schemas App 4 Site Specific Factors (by site) App 5 Histology Exclusion Groups Index to Part I (pg 80 – 84) Appendices (in front!)

  7. What about TNM staging? • Required of physicians in COC programs • NCDB will rely on dr staging until • CS routine in registry • CS derived codes validity assessed • FORDS coding instructions • requires c)TNM and p)TNM when possible • FORDS changes for 2006? --- sigh

  8. General Rules • Should be micro confirmed • Data collected on all sites & histologies • Timing rule • Through completion surgery(ies) if FCOT • Within 4 months dx if no progression • Which is LONGER • NOT 4-month rule any longer

  9. Still General Rules • Greatest EOD based on combined c and p info • If no pre-op treatment, path info priority • If pre-op treatment, clinical info priority • Site specific rules take precedence over general rules

  10. NEW Rule: ‘Inaccessible’ Sites (pg 14) • Regional LN and distant mets negative • NO mention of LN or mets involvement in • PE, Diagnostic testing, Surgical exploration • Patient receives “usual” treatment to site • Only early stage (T1, T2, localized) tumors • Unknown coded if reasonable doubt • No rule change for “accessible” sites • “remainder of exam negative” means negative, not unknown

  11. Primary tumor only Size in mm Priority Path report Imaging PE Invasive In situ if NO invasive Neoadjuvant? Code largest size (pre or post) Residual = NO effect Do NOT add Special rules 990, 998, 999 Melanoma First . . . Tell me the size, Guys CS Tumor Size

  12. Tumor Extension - General • Direct or contiguous (except uterus, ovary) • Ignore + tumor margins or micro residual • If no pre-op, use path • If pre-op, code clinical extension • Unless post-op path is greater than clinical • Imaging has priority over PE • If organ not listed, find in anatomy book • CanNOT be in situ w/LNs or mets

  13. CS Tumor Evaluation • What reports or procedures prove size and extension? • If size is not factor, what proved exten? • Whatever you answer for extension must match your evaluation of how you know • Ex: If you used size and chose 10 for local tumor based on CT only, you cannot use bx code

  14. CS Lymph Nodes • Farthest regional LN chain • Not distant • Path report if no pre-op tx • If pre-op tx, use clinical info • General, size of mets NOT size of node • Use “Inaccessible” rule • If tumor not local, LN could be unknown

  15. 0 PE, imaging, none removed 1 Endoscopy, surg observe, none removed 2 None removed, aut only 3 LN removed w/o pre-surg tx 5 LN removed w/pre-sug tx (info clinical) 6 LN removed w/pre-surg tx (info path) 8 Autopsy only 9 Unk, not documented CS LN Evaluation

  16. CS LN Positive/Examined • Regional LN Positive and LN Examined w/o change • Cumulative field • 01-89 = absolute number • 90  90 LNs • Special codes (aspiration, dissection, etc)

  17. CS Mets at Dx • Discontinuous, blood-borne, implants • Distant LNs • If structure or LN not listed in T Exten or Reg LN, then it’s distant • Ignore mets developing after extent established • “Inaccessible” rule • If tumor not local, mets could be unknown

  18. 0 PE, imaging, no tissue or aut 1 Endoscopy, surg observe, no tiss or aut 2 None removed, aut only 3 Met tiss w/o pre-surg tx 5 Met tiss w/pre-sug tx (info clinical) 6 Met tiss w/pre-surg tx (info path) 8 Autopsy only 9 Unk, not documented CS Mets Evaluation

  19. Site Specific Factors • Site-Specific Factors replace “Tumor Markers” • Necessary for TNM changes • Only used as needed by site • Table 2. pg 13

  20. Histology-Specific Schema • Regardless of site • 8720-8790 Melanoma (multiple schemes) • 9140 Kaposi Sarcoma • 9510-9514 Retinoblastoma • 9590-9699 Lymphoma • 9700-9701 Mycosis Fungoides • 9702-9729 Lympohoma • 9731-9989 Hematopoietic, Myeloproliferative, etc

  21. Data Analysis • Can’t compare to pre-CS • Cases after 1/1/04 • Derived AJCC (6th ed) • Can’t compare to older editions if there were changes • Derived SS 2000 • Will be comparable over time • Caution: If p)TNM, don’t get c)TNM

  22. CS Release 01.02.00 • Why? Correct errors • Required for 2005 cases • Recommends we correct some 2004 cases • Yes? If you will be using CS data • No? NCDB will not penalize

  23. All sites – Histo excluded • NOT KS (9140) or lymphomas to end (9590-9989) • Except Mycosis fungoides (9700), Sezary (9701)

  24. Head & Neck • C00, C01, C02, C03, C04, C05, C06, C07, C08, C09, C10, C12, C13, C14, C32 • Except C10.1, C11

  25. Changes Head/Neck • Note 4 – add to all sites CS Lymph Nodes • Moved supraclavicular lymph nodes from distant to regional lymph nodes • Add SC LN into code 12 on all sites • Remove SC LN from CS Mets • CS Mets at Dx • If CS Mets at Dx = 10 or 50, review case

  26. Lung (C34) • New code 78 CS Extension • 73 (adjacent rib) + • 61-72 multiple T4 statements OR • 74-77 more T4 statements • Review all cases w/61-77 codes to see if new code should be used

  27. Renal Pelvis (C65, C66) • New code 35 CS Extension (to ureter from renal pelvis) • Maps now to T2, RE, RE (not T4) • Make code 62 Obsolete (old 35 definition) • Review/recode old 62

  28. Melanoma • CS Lymph Nodes Code 15 mapping reads N2c RE RN • New CS Reg Nodes Eval • Old referred us to Standard Table • New incorporates satellite/in transit nodules

  29. Melanoma SSF • CS SSF 1 (Thickness) code 990 Obsolete • Incorporated into code 999 • CS SSF4 (LDH) • “Stated as elevated, NOS” added in code 004

  30. Breast (C50) • CS Lymph Nodes • Wording changed for codes 00 and 05 • 00 No Reg LN involvement OR ITCs detected… • 05 “None, no reg LNs but” with (ITC)… • SSF 6 (Invasive?) • “Clinical tumor size coded” added to 888

  31. NCRA Reminders - Inflammatory • Clinical AND pathologic • Often no underlying mass • NOT the same as neglected locally advanced • Path statement of + dermal lymphatics alone NOT enough • Revised codes 71,73 CS Exten to map T4d • Code 72 Obsolete reviewed/change to code 71 per 8/04 changes

  32. NCRA Clarification – CS LN • Isolated Tumor Cells • single tumor cells or small clusters  0.2mm • detected only by IHC or mollecular methods • may be verified on “routine” H&E stains • do not usually show evidence of malignant activity (stromal reaction, etc) • LN with ITC only are NOT considered positive

  33. Corpus Uteri (C54, C55) • CS Extension code 16 reworded • Old: Serosa of corpus (tunica serosa) • New: Tunica serosa of the visceral peritoneum (serosa covering the corpus) • CS Ext Code 60 • Added (parietal lining of the pelvic or abdominal cavity) to explain tunica serosa

  34. Prostate (C61) CS Ext - Clinical • Note 1 reworded (do NOT include prostatectomy info in this field) • Note 2 D Apex information obsolete • New Note 3 (about apex) • Old Notes 3-7 shift down one number • Note 8 reworded (cT versus pT) • Codes 31, 33, and 34 (apex) OBSOLETE

  35. CS Ext (NCRA notes) • Code clinical extension EVEN if prostatectomy • Code groups • 10-15 Clinically INapparent (Not on PE or hypoechoic or other radiographic) • 20-24 Apparent (PE, radiograph) • 30 Local, NOS • 41-49 Peri-prostatic extension • 50-70 Further contiguous extension • Disregard prostatic urethra involvement UNLESS outside prostate

  36. Illustration by Steve Oh / KO Studios; globalrph.mediwire.com www.upmccancercenters.com

  37. nld.by/e/current/stat13.htm#9

  38. Factor 1 (PSA) Code 2 now 002 – 989 for values Round up PSA if needed (0.187 = 0.19) Why record twice? Varies by age of patient < 40 y.o. -- PSA < 2.0 normal Over 75 y.o. -- < 6.5 normal Different labs have different values are positive SSF 1

  39. Note 4 Margins + w/o Extracapsular now T2 Note 5 changed – 031, 033, 034 Obsolete Old Notes 5-8 shift Note 9 reworded (cT versus pT) Code 040 now T2 – REVIEW Code 048 Excludes seminal vesicle margins Code 098 Reworded Prostatectomy performed as FU SSF 3

  40. SSF 4 Apex Involvement • Good news? No more PAP • Bad news? New codes • Review prostates for Apex involvement to recode • May choose NOT to do this • Start with 2005 cases

  41. Apex samples

  42. SSF 5, SSF 6 (Gleason’s) • New Note 1 covers • If 2 numbers in path report (pattern) • If 1 number in path report (pattern versus score) • New Note • If more than one path, choose Gleason’s relating to largest specimen

  43. Gleason Score Conversion 2, 3, 4 = Grade I 5, 6 = Grade II 7, 8, 9, or 10 = Grade III

  44. NCRA Sample: Small nodule felt on DRE in upper posterior lobe. PSA normal (4.5). Needle bx shows Gleason 3+4 adenoca in one lobe. Pt opts for radiation

  45. Testis (C62) • SSF3 040 new? • SF5 (Mets in LN) • Added Note 2 Clinical positive LNs • 001 Clinical N1 nodes • 002 Clnical N2 • 003 Clinical N3 • Code 001 Reworded LN mets <= 2cm AND no extranodal extension

  46. Eyes (C69) • Melanoma Conjunctiva, Iris & Ciliary Body, Choroid • SSF 1: 990 Obsolete (moved to 999) • Melanoma Choroid CS Exten • Code 66 WITH microscopic extraocular exten • Code 68 WITH macroscopic extraocular exten

  47. Brain, Meninges, CNS (C70,C71, C72) • Mapping Change CS Ext Codes 40, 50, 51, 60 from RE in Summary Stage to RNOS

  48. WHO Grading, ICD-O-3 Behavior, "invasive" "slow growing" "malignant" "highly malignant" Grade II Grade I Grade III Grade IV 0 1 3 benign borderline invasive & ICD-O-3 Grade Code WHO GRADE most least aggressive aggressive ICD-O-3 BEHAVIOR ICD-O-3 GRADING gr 1 gr 2 gr 3 gr 4

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